Persistent Vulvovaginal Candidiasis After 5-Day Fluconazole Course
Your infection likely persists because you received an inappropriate regimen: the standard treatment for uncomplicated vaginal candidiasis is a single 150 mg dose of fluconazole, not a 5-day course, and treatment failure mandates diagnostic confirmation before proceeding with alternative therapy. 1, 2, 3
Why Standard Fluconazole Dosing Differs from Your Regimen
The FDA-approved and guideline-recommended dose for uncomplicated vaginal candidiasis is fluconazole 150 mg as a single oral dose, achieving clinical cure rates >90% and mycological eradication in 72–93% of patients. 1, 3, 4
A 5-day daily course is not a standard regimen for vaginal candidiasis in any published guideline; this dosing pattern does not appear in CDC, IDSA, ACOG, or FDA recommendations. 1, 2, 3
The only multi-dose fluconazole regimen recommended is for severe or recurrent disease: fluconazole 150 mg every 72 hours (not daily) for 2–3 doses, totaling 450 mg over 6 days. 1, 2
Immediate Diagnostic Steps Required Before Further Treatment
Do not take additional antifungal medication without laboratory confirmation of ongoing infection. 1, 2, 5
Perform wet-mount microscopy with 10% potassium hydroxide to visualize budding yeast or pseudohyphae; this confirms active infection versus chemical irritation or an alternative diagnosis. 1, 2, 5
Measure vaginal pH with narrow-range pH paper: pH ≤4.5 supports candidiasis, whereas pH >4.5 indicates bacterial vaginosis or trichomoniasis. 1, 2, 5
Obtain a vaginal culture to identify the Candida species, particularly to detect non-albicans species such as Candida glabrata or C. krusei, which are frequently azole-resistant and require alternative therapy. 1, 2, 5
Rule out concurrent sexually transmitted infections, as vulvovaginal candidiasis can coexist with chlamydia, gonorrhea, or trichomoniasis. 2, 5
Treatment Options Based on Diagnostic Findings
If Microscopy Confirms Candida albicans Infection
Switch to extended topical azole therapy for 7–14 days rather than repeating oral fluconazole, because your case now meets criteria for complicated vulvovaginal candidiasis (treatment failure). 1, 2, 5
Effective topical regimens include:
Alternative oral regimen for severe disease: fluconazole 150 mg every 72 hours for 2–3 doses (total 450 mg over 6 days), but only if marked vulvar erythema, edema, excoriation, or fissuring is present. 1, 2
If Culture Identifies Non-Albicans Species (C. glabrata)
First-line therapy: boric acid 600 mg intravaginal gelatin capsules (compounded) daily for 14 days, achieving approximately 70% clinical and mycological eradication. 1, 2, 5
Second-line option: nystatin 100,000 units intravaginal suppositories daily for 14 days. 1, 2
Third-line (specialist referral): topical 17% flucytosine cream ± 3% amphotericin B cream daily for 14 days. 1, 2
C. glabrata accounts for 10–20% of recurrent cases and shows reduced susceptibility to all azole agents, including fluconazole. 1, 2
If Microscopy and Culture Are Negative
Consider alternative diagnoses: contact dermatitis, lichen sclerosus, lichen planus, atrophic vaginitis, bacterial vaginosis, trichomoniasis, or dermatologic conditions. 5
Do not prescribe additional antifungal agents if no yeast is detected; supportive care with emollients and barrier protection is appropriate for chemical irritation. 2, 5
Evaluating for Recurrent Vulvovaginal Candidiasis (RVVC)
If this represents your third or fourth episode within 12 months, you meet criteria for recurrent vulvovaginal candidiasis and require a two-phase treatment approach. 1, 2, 6
Induction phase: 10–14 days of topical azole therapy or fluconazole 150 mg every 72 hours for 3 doses to achieve clinical remission. 1, 2, 6
Maintenance phase: fluconazole 150 mg orally once weekly for 6 months, which controls symptoms in >90% of patients during treatment. 1, 2, 6
Expected outcomes: At 6 months, 90.8% remain disease-free; at 12 months (6 months after stopping therapy), 42.9% remain disease-free versus 21.9% with placebo. 1, 6
Recurrence after maintenance: 40–50% of patients experience recurrence after discontinuing the 6-month course, indicating that RVVC is a chronic condition requiring long-term management rather than a definitive cure. 1, 2, 6
Investigating Predisposing Factors
Evaluate for underlying conditions that promote treatment failure and recurrence:
Uncontrolled diabetes mellitus: hyperglycemia creates a favorable environment for Candida overgrowth. 5
Immunosuppression: HIV infection, corticosteroid use, or chemotherapy increase susceptibility. 5
Recent antibiotic use: broad-spectrum antibiotics disrupt normal vaginal flora. 5
Hormone replacement therapy or high-dose estrogen contraceptives: elevated estrogen levels promote Candida colonization. 5
Critical Pitfalls to Avoid
Do not self-treat with over-the-counter antifungals without microscopic confirmation; self-diagnosis is accurate in only 30–50% of cases. 1, 2
Do not assume all vaginal symptoms are due to yeast infection; bacterial vaginosis and trichomoniasis require distinct treatments and present with overlapping symptoms. 1, 2, 5
Do not treat asymptomatic Candida colonization, which is present in 10–20% of women without infection. 1, 2
Do not routinely treat sexual partners for candidiasis, as it is not a sexually transmitted infection. 2
Do not use nystatin for vaginal candidiasis; topical azoles are significantly more effective. 1, 2